Introduction
Over a number of years at IPC we have undertaken (and continue to be engaged with) a range of research and development work relating to hospital discharge pathways, admission avoidance, and capacity and demand planning. As a result we have established an in-depth understanding of the key features of ‘what good looks like’ across policy and practice.
The challenges for health and care systems are well known and of long standing, although they were thrown into sharp relief during the additional pressures associated with the Covid pandemic. The following are of particular significance:
- Maintaining system flow is fundamental to the optimum efficiency of acute hospitals.
- Extended length of stay leads to rapid deconditioning – particularly for older and frail patients – and associated poorer outcomes.
- Ensuring timely discharge of patients who no longer need hospital care demands clarity over discharge pathways.
- Understanding capacity and demand across the entire health and care system is essential in supporting a Home First strategy, particularly in commissioning recovery and reablement support.
- Assessment of ongoing needs should only take place following a period of recovery and support.
- A ‘single version of the truth’ should be owned by partners with meaningful data and metrics that monitor outcomes beyond length of stay.
Admission avoidance
Continuing problems in managing discharge pathways are reflected in acute hospitals becoming gridlocked, with ambulances queueing to book patients into Accident and Emergency departments; insufficient capacity resulting in extended trolley waits with patients treated in corridors and other spaces poorly suited to quality care; and wards unable to accept admissions without first achieving discharges. People who experience extended stays are typically those awaiting Pathway 2 (P2) discharges (rehabilitation in a bedded setting), while facilitating discharges from those P2 beds can be similarly challenging without active recovery support enabling people to regain independence and return home. For too many people, a discharge on P2 becomes a default admission to permanent residential care.
It is not only the discharge side of the equation that is critical, admission-avoidance is also vital in ensuring that only people in need of acute hospital care are admitted, and that others are supported in the community. There is a need for capacity and demand planning to embrace commissioning of new models of integrated community-based support including:
- Urgent response multi-disciplinary teams.
- Single Point of Access services supporting self-referral.
- Community therapy and equipment services.
- Community nursing and therapist support.
- Community-based intermediate care services.
So far, so familiar, but what might these principles actually look like in practice? Consider the following case study.
A case study in urgent response
Cynthia is aged 95 and living with dementia in her own home with support from her family, and with 3 x daily home care visits 5 times a week. One of her daughters is contacted by the care agency one morning announcing they have found Cynthia on the floor in her bedroom; it isn’t clear what has happened or how long Cynthia has been there, but she can’t get up on her own and the care workers are not permitted to assist. The daughter drives the 30 miles to Cynthia’s house and the care agency dials 999 for an ambulance.
Cynthia does not have a history of falls but she has very poor mobility and has occasionally slid off the bed or sofa onto the floor. A few years ago she became stuck in the bath when she was unable to get out and she spent more than 12 hours in that situation before an alarm was raised. On that occasion she was admitted to hospital and it proved to be a turning point in her independence and capacity; she became much more confused in hospital and experienced delirium. The family are keen to avoid a similar chain of events.
The paramedics arrive at the house about an hour and a half after being called; they are very good in reassuring Cynthia and soon have her off the floor and are able to check her temperature, blood pressure etc. They also do an ECG but are happy the trace doesn’t show anything of concern. The paramedics depart after an hour, but have requested a visit from a community nurse via the urgent response community therapy team, who arrives within an hour and a half and repeats some tests and takes bloods for analysis. Five hours since Cynthia was found on the floor, she has been seen by the paramedics and two community nurses and is back to her normal pattern of engagement, with no recollection of anything that has happened. The Team reassure the daughter that they are not over-concerned about underlying causes, they emphasise that their main priority has been to ensure Cynthia is safe and comfortable, and to avoid a hospital admission if at all possible. They tell the daughter that they work through a Single Point of Access and leave her with a direct phone number she can use for self-referral if there are any concerns in the future.
The case study provides a vivid example of what can be done with all the right services in place; with a community-focused approach achieving a ‘left shift’ from centralised hospital-based response, and a shared understanding of the importance of supporting independence rather than defaulting to risk-averse practices that err on the safe side and admit to hospital ‘just in case.’ Not only was the support timely, high quality and efficient, but it delivered the outcomes that the patient and the family carers valued most highly – ensuring Cynthia’s safety but protecting her autonomy and ability to remain at home. All the people involved in the support expressed their astonishment that Cynthia was doing so well at 95 and highlighted their personal satisfaction in enabling her continued support at home.
This is more than just a happy ending, and a ‘feel good’ case study to illustrate the potential of thinking, commissioning and providing services differently, it is also a very personal matter. Cynthia is my Mother; this is the story of what happened to her this week, and of our great appreciation of the support from the paramedics (who are also studying at Oxford Brookes), and from Oxford Health NHS Foundation Trust, and the Community Therapy Team.
